Central Line Troubleshooting. Beyond the Basics.


    Central Line Troubleshooting. Beyond the Basics.

    Needle, wire, nick, dilate, catheter. Sounds simple right? However, simple doesn’t always mean easy. Placing a central line on a mannequin can be much easier than the 250lb ESRD patient with peripheral vascular disease and a MAP of 50. Below are ten tips to help assist with successful line placement:


    1) Manipulate the syringe plunger prior to the procedure.

    This will lower the initial resistance of a brand new syringe and help make it easier to get blood return when you enter the vein.


    2) Don’t attach the needle to the syringe too tightly.

    The needle should be firmly attached to the syringe, but remember the goal is to be able to remove the syringe without moving the needle tip at all.


    3) Stabilize your needle!

    This is often the step that gives people the most trouble. After you get flash, you must put your entire hypothenar eminence AND all 3 other digits on the patient with a wide base, while you firmly grasp the needle hub with digits 1 and 2.


    4) Wiggle the wire within the nick.

    After you make your nick, wiggle the wire in the nick to make sure it is freely moveable throughout the length of the nick. It is possible to make a nick that is not actually contiguous with your wire tract.


    5) Wet the dilator.

    This helps create less resistance during the dilation process. You can use normal saline from the sterile syringe.


    6) Hold the dilator close to the skin.

    Doing this will give you more control over the dilator and also prevent you from dilating too deeply.


    7) Twist to dilate.

    Remember back to your days of physics class. The coefficient of kinetic friction is usually lower than the coefficient of static friction. Meaning… it’s easier to advance and retract the dilator while it’s already in motion. Twisting upon retraction of the dilator can also be very useful, especially with larger catheters, as the act of removing the catheter often has just as much dilation potential as the insertion.


    8) Dilate at the same angle as you entered the skin.

    Dilating at a different angle from the wire can kink your wire and also lead to additional tissue or vascular trauma.


    9 Keep a shallow angle with big catheters.

    The bigger the dilator and catheter (for example hemodialysis catheters), the more likely you are to penetrate the back wall of the vessel if you advance too steeply.


    10) Double Glove.

    If done under sterile conditions at the beginning of the procedure, one can take off the outer pair of bloody gloves, then secure and bandage the line in place with clean gloves. Cleaner bandage, better protection against needlesticks. Watch for slightly reduced dexterity though.



    Yang L, Mullan B. Reducing needle stick injuries in healthcare occupations: an integrative review of the literature. ISRN Nurs. 2011;2011:315432

    Scott Weingart. EMCrit Wee – Central Line MicroSkills – Dilation. EMCrit Blog. Published on August 29, 2017. Accessed on April 9th 2019. Available at [https://emcrit.org/emcrit/microskills-dilation/ ].

    Scott Weingart. EMCrit Wee – Central Line MicroSkills (Deliberate Practice). EMCrit Blog. Published on September 12, 2015. Accessed on April 9th 2019. Available at [https://emcrit.org/emcrit/central-line-micro-skills-deliberate-practice/ ].

    Triple Lumen Catheter. Digital Image. Nursejanx. April 2018, https://forum.nursejanx.com/t/what-are-the-different-ports-of-a-triple-lumen-central-venous-catheter-used-for/226

    • Welcome! This is the website for the Mount Sinai Emergency Ultrasound Division. It serves as an information resource for residents, fellows, medical students and others seeking information about point-of-care ultrasound. There is a lot ofRead more

    • Lewis Leads & Invisible P’s

      You ever have a tough time visualizing P waves on EKGs? Have no fear, a Lewis Lead EKG might just be the thing you need! The Lewis Lead (aka S5) is a modified EKG obtained in a mannerRead more

    • Head Scratcher of a Head CT?

      Hey there guys and gals and welcome back to my channel! If you’re like me and TERRIBLE at reading your own imaging studies, settle in for a quick 20 minute run down for all thoseRead more

    • Narcan Overdose. Too Much of a Good Thing?

      What do smack, dragon, horse, salt, brown sugar, china white, and black pearl have in common? That’s right… they are all nicknames for heroin. We all know that Naloxone (Narcan) is a useful antidote inRead more

    • Health Information Exchange: Quest for the Omni-Chart.

      Have you ever opened a chart of a very sick or obtunded patient, only to find it completely blank? Of course you have…probably at some point today. The minor panic that having to find vitalRead more

    • Clinical Decision Support…your daily helper.

      Continuing with the theme of clinical informatics, today we will touch on the topic of Clinical Decision Support Systems (CDSS), or sometimes just called Clinical Decision Support (CDS). The basic premise of clinical decision supportRead more

    • What Is Clinical Informatics?

      If you loved the super sexy topic of cerumen impaction yesterday…Well, hold on to your socks, because today we will continue our rousing educational foray by tackling the riveting question: What is Clinical Informatics? ShallRead more

    • Cerumen Impaction: an Update.

      The last time www.sinaiem.org addressed the topic of cerumen (ear wax) impaction was in 2013. See this post: http://sinaiem.org/50yo-man-with-chest-pain-and-also-with-r-ear-pain/  If you’re like me, you likely believe that the world of cerumen impaction is a rather staticRead more

    • Cervical Artery Dissection

      Cervical artery dissection (CAD) accounts for 1-2% of all ischemic strokes but 10-25% of strokes in younger individuals.  CAD includes extracranial carotid and vertebral artery dissections.  A review of the literature suggests that there mayRead more